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Perceived Hospital Stress, Severe Acute Respiratory Syndrome Coronavirus 2 Activity, and Care Process Temporal Variance During the COVID-19 Pandemic

Anesi, George L; Andrews, Adair; Bai, He Julia; Bhatraju, Pavan K; Brett-Major, David M; Broadhurst, M Jana; Campbell, Elizabeth Salvagio; Cobb, J Perren; Gonzalez, Martin; Homami, Sonya; Hypes, Cameron D; Irwin, Amy; Kratochvil, Christopher J; Krolikowski, Kelsey; Kumar, Vishakha K; Landsittel, Douglas P; Lee, Richard A; Liebler, Janice M; Lutrick, Karen; Marts, Lucian T; Mosier, Jarrod M; Mukherjee, Vikramjit; Postelnicu, Radu; Rodina, Valentina; Segal, Leopoldo N; Sevransky, Jonathan E; Spainhour, Christine; Srivastava, Avantika; Uyeki, Timothy M; Wurfel, Mark M; Wyles, David; Evans, Laura
OBJECTIVES:The COVID-19 pandemic threatened standard hospital operations. We sought to understand how this stress was perceived and manifested within individual hospitals and in relation to local viral activity. DESIGN:Prospective weekly hospital stress survey, November 2020-June 2022. SETTING:Society of Critical Care Medicine's Discovery Severe Acute Respiratory Infection-Preparedness multicenter cohort study. SUBJECTS:Thirteen hospitals across seven U.S. health systems. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:We analyzed 839 hospital-weeks of data over 85 pandemic weeks and five viral surges. Perceived overall hospital, ICU, and emergency department (ED) stress due to severe acute respiratory infection patients during the pandemic were reported by a mean of 43% ( sd , 36%), 32% (30%), and 14% (22%) of hospitals per week, respectively, and perceived care deviations in a mean of 36% (33%). Overall hospital stress was highly correlated with ICU stress (ρ = 0.82; p < 0.0001) but only moderately correlated with ED stress (ρ = 0.52; p < 0.0001). A county increase in 10 severe acute respiratory syndrome coronavirus 2 cases per 100,000 residents was associated with an increase in the odds of overall hospital, ICU, and ED stress by 9% (95% CI, 5-12%), 7% (3-10%), and 4% (2-6%), respectively. During the Delta variant surge, overall hospital stress persisted for a median of 11.5 weeks (interquartile range, 9-14 wk) after local case peak. ICU stress had a similar pattern of resolution (median 11 wk [6-14 wk] after local case peak; p = 0.59) while the resolution of ED stress (median 6 wk [5-6 wk] after local case peak; p = 0.003) was earlier. There was a similar but attenuated pattern during the Omicron BA.1 subvariant surge. CONCLUSIONS:During the COVID-19 pandemic, perceived care deviations were common and potentially avoidable patient harm was rare. Perceived hospital stress persisted for weeks after surges peaked.
PMID: 36790189
ISSN: 1530-0293
CID: 5448062

A Novel COVID-19 Severity Score is Associated With Survival in Patients Undergoing Percutaneous Dilational Tracheostomy

Hambrecht, Amanda; Krowsoski, Leandra; DiMaggio, Charles; Hong, Charles; Medina, Benjamin; Thomas McDevitt, John; McRae, Michael; Mukherjee, Vikramjit; Uppal, Amit; Bukur, Marko
INTRODUCTION:Tracheostomy in patients with COVID-19 is a controversial and difficult clinical decision. We hypothesized that a recently validated COVID-19 Severity Score (CSS) would be associated with survival in patients considered for tracheostomy. METHODS:We reviewed 77 mechanically ventilated COVID-19 patients evaluated for decision for percutaneous dilational tracheostomy (PDT) from March to June 2020 at a public tertiary care center. Decision for PDT was based on clinical judgment of the screening surgeons. The CSS was retrospectively calculated using mean biomarker values from admission to time of PDT consult. Our primary outcome was survival to discharge, and all patient charts were reviewed through August 31, 2021. ROC curve and Youden index were used to estimate an optimal cut-point for survival. RESULTS:The mean CSS for 42 survivors significantly differed from that of 35 nonsurvivors (CSS 52 versus 66, P = 0.003). The Youden index returned an optimal CSS of 55 (95% confidence interval 43-72), which was associated with a sensitivity of 0.8 and a specificity of 0.6. The median CSS was 40 (interquartile range 27, 49) in the lower CSS (<55) group and 72 (interquartile range 66, 93) in the high CSS (≥55 group). Eighty-seven percent of lower CSS patients underwent PDT, with 74% survival, whereas 61% of high CSS patients underwent PDT, with only 41% surviving. Patients with high CSS had 77% lower odds of survival (odds ratio = 0.2, 95% confidence interval 0.1-0.7). CONCLUSIONS:Higher CSS was associated with decreased survival in patients evaluated for PDT, with a score ≥55 predictive of mortality. The novel CSS may be a useful adjunct in determining which COVID-19 patients will benefit from tracheostomy. Further prospective validation of this tool is warranted.
PMCID:9676158
PMID: 36914992
ISSN: 1095-8673
CID: 5439642

Angiopoietin-Like4 Is a Novel Marker of COVID-19 Severity

Bhatraju, Pavan K; Morrell, Eric D; Stanaway, Ian B; Sathe, Neha A; Srivastava, Avantika; Postelnicu, Radu; Green, Richard; Andrews, Adair; Gonzalez, Martin; Kratochvil, Christopher J; Kumar, Vishakha K; Hsiang, Tien-Ying; Gale, Michael; Anesi, George L; Wyles, David; Broadhurst, M Jana; Brett-Major, David; Mukherjee, Vikramjit; Sevransky, Jonathan E; Landsittel, Douglas; Hung, Chi; Altemeier, William A; Gharib, Sina A; Uyeki, Timothy M; Cobb, J Perren; Liebler, Janice M; Crosslin, David R; Jarvik, Gail P; Segal, Leopoldo N; Evans, Laura; Mikacenic, Carmen; Wurfel, Mark M
UNLABELLED:Vascular dysfunction and capillary leak are common in critically ill COVID-19 patients, but identification of endothelial pathways involved in COVID-19 pathogenesis has been limited. Angiopoietin-like 4 (ANGPTL4) is a protein secreted in response to hypoxic and nutrient-poor conditions that has a variety of biological effects including vascular injury and capillary leak. OBJECTIVES/OBJECTIVE:To assess the role of ANGPTL4 in COVID-19-related outcomes. DESIGN SETTING AND PARTICIPANTS/METHODS:Two hundred twenty-five COVID-19 ICU patients were enrolled from April 2020 to May 2021 in a prospective, multicenter cohort study from three different medical centers, University of Washington, University of Southern California and New York University. MAIN OUTCOMES AND MEASURES/METHODS:Plasma ANGPTL4 was measured on days 1, 7, and 14 after ICU admission. We used previously published tissue proteomic data and lung single nucleus RNA (snRNA) sequencing data from specimens collected from COVID-19 patients to determine the tissues and cells that produce ANGPTL4. RESULTS:single-nuclear RNA gene expression was significantly increased in pulmonary alveolar type 2 epithelial cells and fibroblasts in COVID-19 lung tissue compared with controls. CONCLUSIONS AND RELEVANCE/CONCLUSIONS:ANGPTL4 is expressed in pulmonary epithelial cells and fibroblasts and is associated with clinical prognosis in critically ill COVID-19 patients.
PMCID:9803343
PMID: 36600780
ISSN: 2639-8028
CID: 5644142

The Role of a Tertiary Level Safety Net Hospital in New York City's 2022 Mpox Outbreak

Lo Piccolo, Anthony J; Wallach, Andrew; McPherson, Tristan D; Mgbako, Ofole; Fagan, Ian; Pitts, Robert A; Klinger, Amanda; Foote, Mary; Garcia, Elizabeth A; Zucker, Jason E; Chan, Justin; Bails, Douglas B; Cohen, Gabriel M; Tennill, Patricia Ann; Wong, Marcia; Mukherjee, Vikramjit
Similar to the early phases of the COVID-19 pandemic, New York City was the national epicenter of the ongoing 2022 mpox (formerly monkeypox) outbreak. Cases quickly began to rise in July 2022, primarily in gay, bisexual, or other men who have sex with men. Tools in the form of a reliable diagnostic test, an effective vaccine, and a viable treatment option have been available from the onset, although logistically complex to roll out. The special pathogens program at NYC Health + Hospitals/Bellevue, the flagship facility for the largest public hospital system in the United States, collaborated with multiple departments within Bellevue, the hospital system, and the NYC Department of Health and Mental Hygiene, to swiftly establish ambulatory testing, immunizations, patient-centered inpatient care, and outpatient therapeutics. With the ongoing mpox outbreak, hospitals and local health departments must prepare a systemwide response to identify and isolate patients and provide high-quality care. Findings from our experience can help guide institutions in developing a multipronged, comprehensive response to the ongoing mpox outbreak.
PMID: 36862506
ISSN: 2326-5108
CID: 5427702

COVID-19 Reinfection and Disease Severity in the New York City Health + Hospitals System [Meeting Abstract]

Smolen, J R; Filardo, T D; George, A; Bhuiyan, S; Kalava, S; Shahin, N; Farkas, J; Mantis, J; Saliaj, M; Mukherjee, V; Salama, C; Eckhardt, B; Cohen, G
Background. Though reinfection with SARS-CoV-2 is well documented, there remains uncertainty about the potential for more severe symptoms with reinfections compared to index infections. Methods. Patients who received SARS-CoV-2 PCR testing between March 1, 2020 and March 1, 2021 at New York City Health and Hospitals (NYC H+H) facilities and had two positive tests>=90 days apart were included in the analysis. Clinical and demographic data were extracted from the electronic medical record. Manual chart review was done to confirm symptomatology, assess COVID-19 related hospital admissions, and determine WHO disease severity. Patients were then classified as unlikely reinfection, possible reinfection, or probable reinfection based on symptomatology, PCR and antibody testing, and lack of alternative diagnoses. Patients were classified as 'unable to be assessed' if symptomatology could not be assessed for both episodes of PCR positivity. Results. During our study timeframe, 1,255,584 unique patients received at least one SARS-CoV-2 PCR test, 265 of whom had two positive tests>=90 days apart. We categorized 20 patients as unable to be assessed, 28 as unlikely reinfection (1 persistent PCR positivity, 27 unlikely true infection at index or second PCR-positive episode), and 217 as possible or probable reinfection. Of the 217, at their index episode 79 had an asymptomatic infection (36.4%) and 17 were severe or critical (7.8%). At their second episode, 162 patients had an asymptomatic infection (74.7%), and 5 were severe or critical (2.3%). Only 24 patients with possible/probable reinfection had a more severe COVID reinfection than index infection, and 20 of the 24 had asymptomatic index infections. Three patients were hospitalized at both episodes, and two deaths possibly attributable to COVID-19 reinfection were noted in this cohort. Figure 3: Change in WHO disease severity classification from index to second infection among probable/possible reinfection cases (n=217) Red indicates increase in disease severity from index to reinfection (n=24), blue indicates decrease in disease severity from index to reinfection (n=100), white indicates no change (n=74) and gray indicates unable to assess disease severity at index or second infection (n=19). Conclusion. COVID-19 reinfection was rare in a high incidence setting among patients tested at NYC H+H facilities. Disease severity was generally milder in reinfection, although severe and critical disease occurred in a small number of patients.These findings from earlier in the pandemic (presumably wild-type and alpha variant) provide data for comparison in understanding how reinfection is evolving with newer variants
EMBASE:640021248
ISSN: 2328-8957
CID: 5513452

Severe Acute Respiratory Infection-Preparedness: Protocol for a Multicenter Prospective Cohort Study of Viral Respiratory Infections

Postelnicu, Radu; Srivastava, Avantika; Bhatraju, Pavan K; Wurfelc, Mark M; Anesi, George L; Gonzalez, Martin; Andrews, Adair; Lutrick, Karen; Kumar, Vishakha K; Uyeki, Timothy M; Cobb, Perren J; Segal, Leopoldo N; Brett-Major, David; Liebler, Janice M; Kratochvil, Christopher J; Mukherjee, Vikramjit; Broadhurst, M Jana; Lee, Richard; Wyles, David; Sevransky, Jonathan E; Evans, Laura; Landsittel, Douglas
Respiratory virus infections cause significant morbidity and mortality ranging from mild uncomplicated acute respiratory illness to severe complications, such as acute respiratory distress syndrome, multiple organ failure, and death during epidemics and pandemics. We present a protocol to systematically study patients with severe acute respiratory infection (SARI), including severe acute respiratory syndrome coronavirus 2, due to respiratory viral pathogens to evaluate the natural history, prognostic biomarkers, and characteristics, including hospital stress, associated with clinical outcomes and severity.
PMCID:9586923
PMID: 36284548
ISSN: 2639-8028
CID: 5359412

View from the frontline: New York city

Chapter by: Mukherjee, Vikramjit; Deshwal, Himanshu; Bhatt, Alok
in: Managing Complexity and COVID-19: Life, Liberty, or the Pursuit of Happiness by
[S.l.] : Taylor and Francis Inc., 2022
pp. 121-129
ISBN: 9781032111933
CID: 5310732

How Common SOFA and Ventilator Time Trial Criteria would have Performed during the COVID-19 Pandemic: An Observational Simulated Cohort Study

Walsh, B Corbett; Pradhan, Deepak; Mukherjee, Vikramjit; Uppal, Amit; Nunnally, Mark E; Berkowitz, Kenneth A
OBJECTIVES/OBJECTIVE:To evaluate how key aspects of New York State Ventilator Allocation Guidelines (NYSVAG)-Sequential Organ Failure Assessment score criteria and ventilator time trials -might perform with respect to the frequency of ventilator reallocation and survival to hospital discharge in a simulated cohort of COVID-19 patients. METHODS:Single center retrospective observational and simulation cohort study of 884 critically-ill COVID-19 patients undergoing ventilator allocation per NYSVAG. RESULTS:742 patients (83.9%) would have had their ventilator reallocated during the 11-day observation period, 280 (37.7%) of whom would have otherwise survived to hospital discharge if provided a ventilator. Only 65 (18.1%) of the observed surviving patients would have survived by NYSVAG. Extending ventilator time trials from 2 to 5 days resulted in a 49.2% increase in simulated survival to discharge. CONCLUSIONS:In the setting of a protracted respiratory pandemic, implementation of NYSVAG or similar protocols could lead to a high degree of ventilator reallocation, including withdrawal from patients who might otherwise survive. Longer ventilator time trials might lead to improved survival for COVID-19 patients given their protracted respiratory failure. Further studies are needed to understand the survival of patients receiving reallocated ventilators to determine whether implementation of NYSVAG would improve overall survival.
PMID: 35678391
ISSN: 1938-744x
CID: 5248482

Special Pathogens Readiness in the United States: From Ebola to COVID-19 to Disease X and Beyond

Sauer, Lauren M; Mukherjee, Vikramjit
PMID: 35588287
ISSN: 2326-5108
CID: 5282982

Maintaining Standards of Care in the Era of Special Pathogens

Postelnicu, Radu; Mukherjee, Vikramjit; Uppal, Amit; Hick, John L
PMID: 35575728
ISSN: 2326-5108
CID: 5282962